Clipping of an anterior spinal artery aneurysm using an endoscopic fluorescence imaging system for craniocervical junction epidural arteriovenous fistula: technical note

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The authors report the case of a 78-year-old man with a craniocervical junction epidural arteriovenous fistula who presented with subarachnoid hemorrhage from a ruptured anterior spinal artery (ASA) aneurysm. Because endovascular embolization was difficult, a posterolateral approach was chosen and a novel endoscopic fluorescence imaging system was utilized to clip the aneurysm. The fluorescence imaging system provided clear and magnified views of the ventral spinal cord simultaneously with the endoscope-integrated indocyanine green videoangiography, which helped safely obliterate the ASA aneurysm. With the aid of this novel imaging system, surgeons can appreciate and manipulate complex vascular pathologies of the ventral spinal cord through a posterolateral approach, even when the lesion is closely related to the ASA.

ABBREVIATIONS ASA = anterior spinal artery; AVF = arteriovenous fistula; CCJ = craniocervical junction; DSA = digital subtraction angiography; EDAVF = epidural AVF; ICG = indocyanine green; SAH = subarachnoid hemorrhage.

Article Information

Correspondence Toshiki Endo: Kohnan Hospital, Sendai, Japan. endo@nsg.med.tohoku.ac.jp.

INCLUDE WHEN CITING Published online April 26, 2019; DOI: 10.3171/2019.1.SPINE18983.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    Preoperative images on admission. Left: CT showing SAH predominantly in the CCJ. Right: Sagittal T2-weighted MRI showing a flow void signal on the ventral spinal cord at C2 (arrow).

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    Preoperative selective DSA. Left: Anteroposterior view of the selective right vertebral artery angiogram showing an aneurysm of the vasa corona from the ASA (large arrow) and fusiform dilation of the feeding artery (small arrow). This artery fed the right C2 EDAVF. The arrowhead indicates a fistulous point. The fistula was also fed by a C2 radicular artery (asterisk). Right: Three-dimensional reconstructed image demonstrating the same angioarchitecture as in the left panel. Arrows show feeder aneurysms of the fistula (arrowhead). Asterisk indicates a C2 radicular artery, a feeder of the EDAVF.

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    Intraoperative images during clipping of the ASA aneurysm. A: Microscopic view. Following suboccipital craniotomy, C1 hemilaminectomy, and C2 upper partial hemilaminectomy, the epidural venous pouch was found at the right C2 (arrowhead). B: Microscopic view. Following the dural incision, two feeder aneurysms were noted. The aneurysm (large arrow) and fusiform dilation (small arrow) corresponded to the angiogram (Fig. 2). C: Endoscopic view. The aneurysm located next to the ASA was clipped using a Yaşargil titanium clip. D: Endoscopic view. Image from ICG videoangiography. The ASA was preserved (arrowheads). E: Endoscopic view. Fusion image from the PINPOINT system. Because ICG videoangiography was fused with the anatomical image, this system can clearly demonstrate the obliteration of the aneurysm and the preservation of the ASA (arrowheads). Figure is available in color online only.

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    Postoperative images. A: Sagittal T2-weighted MR image showing no spinal cord injury. B: CT scan demonstrating extent of bone removal in C1. Note an arrow indicating the aneurysm clip. C: Selective right vertebral artery angiogram. Three-dimensional reconstructed image from a rotational angiogram confirming complete obliteration of the aneurysm and preservation of the ASA. The asterisk indicates the right C2 radicular artery and the arrow indicates an aneurysm clip.

References

  • 1

    Amelot ATerrier LMLot G: Craniovertebral junction transoral approach: predictive factors of complications. World Neurosurg 110:5685742018

  • 2

    Brinjikji WYin RNasr DMLanzino G: Spinal epidural arteriovenous fistulas. J Neurointerv Surg 8:130513102016

  • 3

    Clarke MJPatrick TAWhite JBCloft HJKrauss WELindell EP: Spinal extradural arteriovenous malformations with parenchymal drainage: venous drainage variability and implications in clinical manifestations. Neurosurg Focus 26(1):E52009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Endo TEndo HSato KMatsumoto YTominaga T: Surgical and endovascular treatment for spinal arteriovenous malformations. Neurol Med Chir (Tokyo) 56:4574642016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Endo TShimizu HSato KNiizuma KKondo RMatsumoto Y: Cervical perimedullary arteriovenous shunts: a study of 22 consecutive cases with a focus on angioarchitecture and surgical approaches. Neurosurgery 75:2382492014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Fengler J: Near-infrared fluorescence laparoscopy—technical description of PINPOINT® a novel and commercially available system. Colorectal Dis 17 (Suppl 3):362015

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Hemphill JC IIISmith WSHalbach VV: Neurologic manifestations of spinal epidural arteriovenous malformations. Neurology 50:8178191998

  • 8

    Hida KShirato HIsu TSeki TOnimaru RAoyama H: Focal fractionated radiotherapy for intramedullary spinal arteriovenous malformations: 10-year experience. J Neurosurg 99 (1 Suppl):34382003

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Hiramatsu MSugiu KIshiguro TKiyosue HSato KTakai K: Angioarchitecture of arteriovenous fistulas at the craniocervical junction: a multicenter cohort study of 54 patients. J Neurosurg 128:183918492018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Ito AEndo TInoue TEndo HSato KTominaga T: Use of indocyanine green fluorescence endoscopy to treat concurrent perimedullary and dural arteriovenous fistulas in the cervical spine. World Neurosurg 101:814.e1814.e62017

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Kim JLee JBCho THHur JW: Incidental occlusion of anterior spinal artery due to Onyx reflux in embolization of spinal type II arteriovenous malformation. Eur Spine J 26 (Suppl 1):75792017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Kinouchi HMizoi KTakahashi ANagamine YKoshu KYoshimoto T: Dural arteriovenous shunts at the craniocervical junction. J Neurosurg 89:7557611998

  • 13

    Kiyosue HMatsumaru YNiimi YTakai KIshiguro THiramatsu M: Angiographic and clinical characteristics of thoracolumbar spinal epidural and dural arteriovenous fistulas. Stroke 48:321532222017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Kiyosue HTanoue SOkahara MHori YKashiwagi JMori H: Spinal ventral epidural arteriovenous fistulas of the lumbar spine: angioarchitecture and endovascular treatment. Neuroradiology 55:3273362013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Krings TMull MBostroem AOtto JHans FJThron A: Spinal epidural arteriovenous fistula with perimedullary drainage. Case report and pathomechanical considerations. J Neurosurg Spine 5:3533582006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Kurokawa YIkawa FHamasaki OHidaka TYonezawa UKomiyama M: [A case of cervical spinal dural arteriovenous fistula with extradural drainage presenting with subarachnoid hemorrhage due to a ruptured anterior spinal artery aneurysm.] No Shinkei Geka 43:8038112015 (Jpn)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Markert JMChandler WFDeveikis JPRoss DA: Use of the extreme lateral approach in the surgical treatment of an intradural ventral cervical spinal cord vascular malformation: technical case report. Neurosurgery 38:4124151996

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Martin NAKhanna RKBatzdorf U: Posterolateral cervical or thoracic approach with spinal cord rotation for vascular malformations or tumors of the ventrolateral spinal cord. J Neurosurg 83:2542611995

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Nakagawa IPark HSHironaka YWada TKichikawa KNakase H: Cervical spinal epidural arteriovenous fistula with coexisting spinal anterior spinal artery aneurysm presenting as subarachnoid hemorrhage—case report. J Stroke Cerebrovasc Dis 23:e461e4652014

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20

    Niizuma KEndo TSato KTakada SSugawara TMikawa S: Surgical treatment of spinal extradural arteriovenous fistula with parenchymal drainage: report on 5 cases. Neurosurgery 73 (2 Suppl Operative):onsE287onsE2942013

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21

    Raabe ANakaji PBeck JKim LJHsu FPKamerman JD: Prospective evaluation of surgical microscope-integrated intraoperative near-infrared indocyanine green videoangiography during aneurysm surgery. J Neurosurg 103:9829892005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Rangel-Castilla LHolman PJKrishna CTrask TWKlucznik RPDiaz OM: Spinal extradural arteriovenous fistulas: a clinical and radiological description of different types and their novel treatment with Onyx. J Neurosurg Spine 15:5415492011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Ris FBuchs NCMorel PMortensen NJHompes R: Discriminatory influence of Pinpoint perfusion imaging on diversion ileostomy after laparoscopic low anterior resection. Colorectal Dis 17 (Suppl 3):29312015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Roccatagliata LKominami SKrajina ASellar RSoderman MVan den Berg R: Spinal cord arteriovenous shunts of the ventral (anterior) sulcus: anatomical, clinical, and therapeutic considerations. Neuroradiology 59:2892962017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Sato KEndo TNiizuma KFujimura MInoue TShimizu H: Concurrent dural and perimedullary arteriovenous fistulas at the craniocervical junction: case series with special reference to angioarchitecture. J Neurosurg 118:4514592013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Silva N JrJanuel ACTall PCognard C: Spinal epidural arteriovenous fistulas associated with progressive myelopathy. Report of four cases. J Neurosurg Spine 6:5525582007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Takai KTaniguchi M: Comparative analysis of spinal extradural arteriovenous fistulas with or without intradural venous drainage: a systematic literature review. Neurosurg Focus 32(5):E82012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Tsutsui NYoshida MKitajima MSuzuki Y: Laparoscopic cholecystectomy using the PINPOINT endoscopic fluorescence imaging system with intraoperative fluorescent imaging: a case report. Int J Surg Case Rep 21:1291322016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Tsutsui NYoshida MNakagawa HIto EIwase RSuzuki N: Optimal timing of preoperative indocyanine green administration for fluorescent cholangiography during laparoscopic cholecystectomy using the PINPOINT® Endoscopic Fluorescence Imaging System. Asian J Endosc Surg 11:1992052018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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